3 of 50 - OPWDD naming convention for the specific ... 3 of 50. 4 of 50 Page 2 A. Agency...

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HCBSSettingsHeightenedScrutinyProviderEvidenceQuestionnaireSelf-Report

GENERALINSTRUCTIONS

1. AllHCBSWaiverprovidersmustcompleteSectionA.“AgencyInformation”.

2. TheHCBSWaiverprovidermustself-identifywhichresidentialandnon-residentialsettings(excludingshelteredworkshopsthatmustclose/convert)triggerheightenedscrutinyandthencomplete1questionnairepereachofthesesettings(SectionsB-G).Providersmustinclude:

SettingsdeemedheightenedscrutinybyDQIsurveyorsviaexitconferenceformorletter;

AND:

SettingsnotyetassessedbyDQIwheretheproviderself-identifiesthesiteasrequiringheightenedscrutiny;

AND:

Settingstheproviderself-identifiesthattheybelieveshouldhavebeendeemedheightenedscrutinybyDQIsurveyorsbutwerenot.

OPWDDwilllaterreconcileDQI’slistofheightenedscrutinysettingswithquestionnairesreceivedfromproviderstoensureallheightenedscrutinysiteshavebeenidentified.InformationsubmittedcomprisestheHeightenedScrutiny“EvidencePackage”andwillbesubjecttovalidationbyNewYorkState.TheEvidencePackagemaybemadepublicallyavailableduringtherequiredpublicinputprocessandthereforeprovidersshouldnotincludenamesoranyotherpersonal/confidentialinformationprotectedbyFederalorStateLawonpeoplesupportedthroughthesetting.Inadditiontothequestionnaire,thefollowinginformationisrequiredfortheEvidencePackageandwillbeuploadedtoFluidSurveys.

3. SITEMAP(SectionD):AsitemapofthelocationoftheheightenedscrutinysettingmustbeuploadedtoFluidSurveys.Sitemapscanbeobtainedathttp://maps.google.com(oncethereclickthesatellitebutton).Itisrecommendedthatyoucopyandpastethislinkintoaseparatebrowserasyoumayberedirectedawayfromthissurvey.Identifyallsettingsonthesitemapbyagency,OC#,address,andcertifiedcapacity.Identifythesettingsthatarecollocatedand/orclusteredwiththeheightenedscrutinysettingaswellbyagency,OC#,addressandcertifiedcapacity.Otherlocationsshouldalsobeidentifiedsuchasprivatehomes,grocerystores,parks,banks,etc.Beforeuploading,savetheimagewiththefollowingnamingconventionforthespecificheightenedscrutinysettingthatisthesubjectofthesurvey:Agency-OC#-sitemap.

4. PICTURES(SectionD):UploadtotheFluidSurveysupto5picturesthatdepictthesettingandsurroundingneighborhood.Donotincludepicturesofpeopleyousupport.Beforeuploading,savetheimagewiththefollowingnamingconvention:Agency-OC#-pic_of_(e.g.,OPWDD-12345678-pic1of5).

5. QUESTIONNAIRE(SectionE-1andE-2):SectionE-1istobecompletedforallsettingsthattriggeredheightenedscrutiny.Thesequestionsaretobeansweredforallsettingswherewaiverservicesaredelivered.QuestionsinSectionE-2arespecifictothetypeofsetting(i.e.,residentialordaysetting).Select"residential"foranassessmentbeingcompletedforaresidentialsettingand"non-residential"foranassessmentbeingcompletedforanon-residentialsetting.

6.WORKPLAN(SectionF):Aworkplanmustbeprovidedforanyheightenedscrutinysettingthatisnotinfullcompliance

HeightenedScrutiny

APPENDIX B

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withtheHCBSsettingsrules.Evenoneresponseof“No”indicatesthataworkplanisneeded.UploadtotheFluidSurveysthesetting’sworkplanthatshowshowfullcompliancewiththeHCBSsettingsrequirementsandstandardswillbeachievednolaterthanOctober1,2018.Beforeuploading,savetheworkplanwiththefollowingnamingconvention:Agency-OC#-wp.

7. NARRATIVE(SectionG):IncludenarrativeinformationthatclearlydemonstrateshowthesettingmeetstheHomeandCommunityBasedSettingsrequirementsandovercomesthepresumptionthatitisinstitutionaland/orisolating.FocustheresponseonhowthesettingprovidesfullaccessforEACHPERSONservedthroughthesettingtothebroadercommunityincludingopportunitiestoseekemployment,workincompetitiveintegratedsettings,engageincommunitylife,controlpersonalresources,andreceiveservicesinthecommunitytothesamedegreeofaccessaspeoplenotreceivingHCBSservices.Additionally,agenciesshouldalsoprovideevidencedemonstratingthatthereislittleornointerconnectednessoftheadministrativeandfiscaloperationsofco-locatedoradjacentsettings.Ifthespaceprovidedinthequestionnaireisnotsufficient,consolidatealladditionalinformationintoonefile/formatanduploadtotheFluidSurveys.Beforeuploading,savetheadditionalinformationwiththefollowingnamingconvention:Agency-OC#-addinfo.

INSTRUCTIONSONUSINGTHISSURVEY:Itisrecommendedthatyoucopyandpastethelinksbelowintoaseparatebrowserasyoumayberedirectedawayfromthissurvey.

GATHERINFORMATIONNEEDED:ItisrecommendedthatbeforeproceedingwiththeelectronicsurveyinFluidSurveys,yougatherallthenecessaryinformationonthesettingsthattriggerheightenedscrutinyasdefinedbytheOctober2015ProviderCommunicationMemoonheightenedscrutinythatcanbefoundat:http://www.opwdd.ny.gov/node/6252Informationneededontheagencyandeachsettingincludes,butisnotlimitedto,thefollowing:

AgencyCorporateIDandagencycontactpersonandcontactinformationAgencyaccreditationsifanyandwhethertheagencyisdesignatedasafullCOMPASSagencyOperatingCertificatenumbersforeachHSsettingContactpersonandcontactinformationforeachHSsettingshouldadditionalinformationbeneededAddressesforeachHSsettingandcountywhereeachHSsettingislocatedCertifiedcapacityofeachHSsettingNumberofpeopleservedthrougheachHSsettingThespecificHStriggersforeachHSsetting(seehttp://www.opwdd.ny.gov/node/6252)Whetherthesettingisco-locatedand/orclusteredwithothersettingsandtheAgency,OC#s,certifiedcapacitiesoftheothersettingsCharacteristicsofeachHSsetting(e.g.,whetherpublictransportationisavailable,buildingtype,locationtype,etc.)HSSettingSiteMap-Sitemapscanbeobtainedathttp://maps.google.com(oncethereclickthesatellitebutton).HSsettingpicturesHSsettingWorkPlan(anoptionaltemplatecanbefoundontheHCBSSettingsToolkitat:http://www.opwdd.ny.gov/opwdd_services_supports/HCBS/hcbs-settings-toolkitunder“HeightenedScrutiny”)

USEBACKORNEXTBUTTON:Whenmovingthroughthesurveyon-line,ifyouneedtogobackorforwardtoapage,usethe“Back”or“Next”buttononthebottomofthesurveypage.SAVEANDCONTINUEOPTION:Withinthissurvey,youaregiventheopportunityto“SaveandContinue”(seebuttonatthebottomofeverysurveypage).Thiswillallowyoutosaveyoursurveyandtocontinueyoursurveyatalaterdate.Whenyouclick“SaveandContinue”youwillseeaURLthatyoucanbookmarktocontinuethesurveylater.WehighlyrecommendthatyoubookmarkthisURLsothatyoucancontinueyoursurveyatalaterdate.Or,youcanenteryouremailaddressandclick“Emailmethislink”.FluidSurveyswillthenautomaticallyemailyouthesurveylink(whichyoualsohavebookmarkedasmentionedabove)foryoutousetocontinuewhereyouleftoff.Thisemailwillcomefromheightened.scrutiny@opwdd.ny.govviaFluidSurveys.NOTE:PleasebesuretocheckyourspamandjunkfoldersifyoudonotreceiveanautomaticemailfromFluidSurveys.OPWDDisnotabletogenerateanother“SaveandContinue”emailifthe“SaveandContinue”emailisnotautomaticallyreceivedduetobeingblockedbyyouragency.Shouldyounotreceiveyour“SaveandContinue”emailfromFluidSurveysanddonotbookmarkyourURL,youwillhavetorestartyoursurveyfromthebeginning.SUBMITTINGTHESURVEYANDDOWNLOADING/PRINTINGIT:Beforeyouclickthe“SUBMIT”buttonattheendofeachsurvey,pleasereviewyouranswersasyouwillnotbeabletochangetheresponsestoyoursurveyunlessyoucontactCaseyDowneyat518-486-9863 [email protected]“Submit”buttonattheendofthesurvey,youwillhavethechancetodownload/printyoursurveyresponse.STARTINGANOTHERSURVEY:Tostartanothersurveyforaparticularheightenedscrutinysetting,youwillhavetotypethesurveylinkbackintoyourbrowsertotakethesurveyagainbyusingthislink:http://opwddnygov.fluidsurveys.com/s/HeightenedScrutiny/FORQUESTIONSANDTROUBLESHOOTINGCONTACT:CaseyDowney,OPWDD,ProgramOperationsSpecialist,518-486-9863 oremailheightened.scrutiny@opwdd.ny.gov.Thankyouforyourtimeincompletingthisimportantsurvey.

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Page2A.AgencyInformation:

NOTE:Allquestionsarerequiredforyourfirstsurvey.Forallsubsequentsurveys,onlyquestions#1,#2,#2a,and#5arerequired.

1)ProviderAgencyName:

ANSWERREQUIREDFOREVERYSURVEYCOMPLETED

Typehere

1a)Agencycontactperson'sFIRSTname:

ONLYREQUIREDONFIRSTSURVEYSUBMISSION

Typehere

1b)Agencycontactperson'sLASTname:


Typehere

1c)Agencycontactperson'sphonenumber(XXX-XXX-XXXX):


Typehere

1d)Agencycontactperson'se-mailaddress:


Typehere

(CorpID)

2)AgencyCorporateID(5characters):


Typehere

2a)Re-enterAgencyCorporateID(5characters):


Typehere

3)Istheagencyaccreditedbyacertifyingbody?


3a)Whatagencyaccreditation(s)?


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3b)CQLAccreditationType


4)IstheagencyafullCOMPASSagency?


5)DoestheagencyhaveanysitesthattriggerHeightenedScrutiny?

ANSWERREQUIREDFOREVERYSURVEYCOMPLETEDIfno,youwillbesenttothesurveycompletionpage.

(sites)

5a)Iftheagencyhassitesthattriggerheightenedscrutiny:

ONLYREQUIREDONFIRSTSURVEYSUBMISSIONEnteranumericvalueonly(nodecimalsorfractions).Ifnone,enter0.

Numberofcertifiedresidentialsettingsthattriggerheightenedscrutiny: Typehere

Numberofcertifieddayhabilitationsettingsthattriggerheightenedscrutiny:

Typehere

Numberofcertifieddaytrainingsettings(thatarenotshelteredworkshops)thattriggerheightenedscrutiny:

Typehere

Numberofothersettingsthattriggerheightenedscrutiny: Typehere

(sumofsites)

Thetotalsettingsoperatedbyyouragencythattriggerheightenedscrutinyis(sumoftheabove):

{{sites.0+sites.1+sites.2+sites.3}}

5b)Specifythetypeofothersettingsthattriggeredheightenedscrutiny:


Typehere

CQL

Other,pleasespecify... Typehere



QualityAssurances

PersonCenteredExcellence

PersonCenteredExcellencewithDistinction

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Page3B.DemographicInformationforHeightenedScrutinySite:

Allquestionsarerequired

CompletesectionsB-FforEACHsettingthattriggersheightenedscrutiny.

1)TypeofCertifiedSetting-Only1answerbasedonO.C.#:

2)SiteAddress:

Typehere

2a)SiteCity:

Typehere

2b)SiteZip:

Typehere

3c)SiteCounty:

SupervisedIRAorCR

SupportiveIRAorCR

DayHabilitation

DayTraining(SitebasedPrevocationalSettingotherthanShelteredWorkShop)


Albany

Allegany

Bronx

Broome

Cattaraugus

Cayuga

Chautauqua

Chemung

Chenango

Clinton

Columbia

Cortland

Delaware

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Dutchess

Erie

Essex

Franklin

Fulton

Genesee

Greene

Hamilton

Herkimer

Jefferson

Lewis

Kings

Livingston

Madison

Monroe

Montgomery

Nassau

NewYork

Niagara

Oneida

Onondaga

Ontario

Orange

Orleans

Oswego

Otsego

Putnam

Queens

Rensselaer

Richmond

Rockland

St.Lawrence

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PleaseNote:TheOCnumberisan8-digitnumber.Historically,theOCnumberhadonly7-digits.Withthetransitiontothe7to8digitOC,theOCnumbersremainunchangedwiththeexceptionofa0beinginsertedasthe5thdigit.AllOC's

shouldbeformatedas:

XXXX0XXX

(OpCert)

3)OperatingCertificateNumber(8digits):

Typehere

4)Re-enterOperatingCertificateNumber(8digits):

Typehere

5)CertifiedCapacity:

Typehere

5b)Numberofpeopleenrolledintheprogramwhousethesetting:

Typehere

(Name)

6)Contactperson'sFIRSTname:

Saratoga

Schenectady

Schoharie

Schuyler

Seneca

Steuben

Suffolk

Sullivan

Tioga

Tompkins

Ulster

Warren

Washington

Wayne

Westchester

Wyoming

Yates

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Typehere

6b)Contactperson'sLASTname:

Typehere

7)Contactphonenumber(format:XXX-XXX-XXXX):

Typehere

8)Contacte-mail:

Typehere

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Page4C.HeightenedScrutiny(HS)Triggers:IndicatewhatHeightenedScrutinytrigger(s)applytoyoursite/settingyou

arecompletingthesurveyfor.MoreinformationontheHStriggerscanbefoundat:

http://www.opwdd.ny.gov/node/6252(NOTE:ifyouclickonthislink,youmaybetakenawayfromthissurvey.Pleasecopyandpastethislinkintoa

separatebrowser).Allquestionsarerequired

1.Thesetting/siteislocatedinabuildingonthegroundsofapublicinstitution.(Apublicinstitutionisaninstitutionthatistheresponsibilityofagovernmentalunitoroverwhichagovernmentalunitexercisesadministrativecontrol.ThefollowingisNOTapublicinstitutionforpurposesofheightenedscrutiny:Medicalinstitutions,childcareinstitutions,universities,hospitals,schools,publiclibrariesorothersimilarsettings.)

2.Thesetting/siteislocatedinabuildingthatisalsoapublicallyorprivatelyoperatedfacilitythatprovidesinpatientinstitutionaltreatment.

3.Thesetting/siteisimmediatelyadjacenttoapublicinstitution(i.e.thesetting/siteisnexttoandabutsthepublicinstitution,seedefinitionin1.).

4.Thesetting/sitehasbeenconvertedfromanIntermediateCareFacility(ICF)onorafterMarch17,2014.

4a.Ifyesto#4,indicatedateofconversion(MM/DD/YYYY):

Typehere

5.Thesetting/siteispartofagroupofmultiplesettingsco-locatedandoperationallyrelatedsuchthattheco-locationand/orclusterappearstoisolateand/orinhibitinteractionwiththebroadercommunity,includinganyofthefollowing:

5a.Setting/siteissituatedonaPRIVATECAMPUSwheretherearemultiplegrouphomesand/orfacilitiesforpeoplewithintellectualand/ordevelopmentaldisabilities(I/DD)onthesameproperty(NOTE:Privatecampussettingswillautomaticallytriggerheightenedscrutiny);and/or

5b.Settingisco-locatedwithmultiplesettingsforpeoplewithintellectualand/ordevelopmentaldisabilities(I/DD)thatareoperationallyrelatedsuchthattheco-locationmayisolatepeoplewithdisabilitiesand/orinhibitindividualsfrominteractingwiththebroadercommunity.

5c.Howmanysettings/programsareclustered,co-located,oronaprivatecampus?

Typehere

5d.Howmanypeopleareservedintheclustered,co-located,orprivatecampussettings/programs?

Typehere

6.Thesetting/sitesdesign,appearance,and/orlocationappearstobeinstitutionaland/orisolating(includesoneormoreof

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thefollowingcriteria):Thesetting/siteisclustered(i.e.adjacentto,incloseproximitytoothersettings/sitesforpeoplewithdisabilities)suchthattheclustermayisolatepeopleand/orinhibitinteractionwiththebroadercommunity);thesettingisdesignedtoprovidepeoplewithdisabilitiesmultipletypesofservicesandactivitiesonthesamesite(e.g.,housing,dayservices,medical,behavioral,therapeutic,and/orsocialandrecreationalactivities)(i.e.,peoplewithdisabilitieshavelittletonointeraction/experiencesoutsideofthesetting);resultinginlimitedautonomyand/orregimentedservices;Peopleinthesettinghavelimitedifanyinteractionwiththebroadercommunity(i.e.thesettingissetupandoperatedinsuchawaythatpeoplewithdisabilitieshavelimitedtonointeractions/experiencesoutsideofthesetting,regardlessofthesettingslocation);and/or;thesetting/siteunderreviewappearstobemoreisolatingthanothersettingsinthesamevicinity/neighborhoodand/orCMSguidancehasspecificallymentionedthesettingtypeasasettingpresumedtoisolate.Forexample:settingisagatedcommunity;settingisafarmsteadordisabilityspecificfarmcommunity;settingisaresidentialschool;settinghasfencing,gates,orotherstructuralitemsthatsetsitapartfromtheneighborhood/community;settingislabeledbysignageasafacilityforpeoplewithdisabilities;settingisclosetoapotentiallyundesirablelocation(e.g.,dump,factory,acrossthestreetfromaprisonorotherinstitutionalsetting,etc.)thatisisolatingand/orinhibitsindividualsfrominteractingwiththebroadercommunity;and/or;settinghasvideocamerasurveillanceinsidethesetting.

6a.Ifyesto#6,cantheheightenedscrutinytriggerbechangedpriorto10/1/2018?Forexample,ifpeoplehavelimitedaccesstothebroadercommunity,theprovidercanimplementchangestofacilitatemorefrequentandindividualizedaccesstothebroadercommunityforeachperson.

6b)Ifyesto6a,explainhowitcanbechanged:

Typehere

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Page5D.SettingLocation:


1)SettingLocationType:

2)Ispublictransportationavailable?

2a)Ifpublictransportationisavailable,doesthesettingprovidecontactinformation,accessto,andtrainingontheuseofpublictransportation,andaretransportationschedulesandphonenumbersavailableinaconvenientlocationforpeoplesupportedtoaccess?

2b)Ifpublictransportationisnotavailable,areotherresourcesprovidedforthepersontoaccessthebroadercommunity?

3)Buildingtype:

(home)

3a.Multi-FamilyHome:Numberoftotalunits

Typehere

3b.Multi-FamilyHome:NumberofdesignatedunitsforpeopleservedbyOPWDD/HCBSWaiverServices

Typehere

(apartment)

3a.ApartmentBuilding:Numberoftotalunits

Typehere

3b.ApartmentBuilding:NumberofdesignatedunitsforpeopleservedbyOPWDD/HCBSWaiverServices

Rural

Suburban

Urban

SingleFamilyHome

Multi-FamilyHome

ApartmentBuilding

DayFacility-SingleBuilding

DayFacility-Partofastripmall,businesspark,orothercommercial/integratedlocation

DayFacility-Partofaclusterorco-locationonsamepropertywithotherfacilitiesonlyservingpeoplewithI/DD


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Typehere

SiteMap(NamingConvention:Agency-OC#-Sitemap):

AsitemapofthelocationoftheheightenedscrutinysettingmustbeuploadedtoFluidSurveys.Sitemapscanbeobtainedathttp://maps.google.com(oncethereclickthesatellitebutton).Itisrecommendedthatyoucopyandpastethislinkintoaseparatebrowserasyoumayberedirectedawayfromthissurvey.Identifyallsettingsonthesitemapbyagency,OC#,address,andcertifiedcapacity.Identifythesettingsthatarecollocatedand/orclusteredwiththeheightenedscrutinysettingaswellbyagency,OC#,addressandcertifiedcapacity.Otherlocationsshouldalsobeidentifiedsuchasprivatehomes,grocerystores,parks,banks,etc.Beforeuploading,savetheimagewiththefollowingnamingconventionforthespecificheightenedscrutinysettingthatisthesubjectofthesurvey:Agency-OC#-sitemap.

Chooseafiletoupload NofileselectedChooseFile

Uploadupto5picturesthatdepictthesettingandsurroundingareaifnecessarytoassistingtheheightenedscrutinyprocess.Atleastonepictureisrequired.

BESUREYOURUPLOADSARESAVEDWITHTHENAMINGCONVENTIONOFAGENCY-OC#-PICXOFX(EX.OPWDD-12345678-PIC1OF4)

Picture1

Required


Picture2


Picture3


Picture4


Picture5


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Page6

E-1.PERSONCENTEREDHABILITATIONPLANNINGANDSERVICEDELIVERY:


1)Peoples’HabilitationPlansaredevelopedandupdatedusingapersoncenteredplanningprocessthatreflectstheirdreams,interests,preferences,strengths,capacities,andinformedchoices;consequentlytheirPlansdriveactivitiesandsupportsthataremeaningfultoeachperson.

1a)Specifytheworkplanactionitems.

CheckallthatapplyandattachdetailedWorkPlaninSectionF.

2)Peoplemakeinformedchoicesrelatedtohome,work,relationships,recreationalactivities,socialroles,etc.



Reviewandreviseservice/habilitationplansusingapersoncenteredmethodology(includedescriptioninformationinSectionF)

Trainsettingstaffonpersoncenteredplanningrightsandhonoringchoices

Trainstaffresponsibleforthewritingandcoordinationofservice/habilitationplans

Trainindividualssupportedontheirrightsandhowtomakeinformedchoices

Trainfamiliesand/oradvocatesontherightsofindividualsandhowtomakeinformedchoices

Reorganizeand/orreallocatestaffingandorincreaseresourcestoensuresufficientstaffingtoaddresspeople'spreferences

Increaseaccesstoactivitesandoptionsthatareofinteresttopeoplesupported

Reorganizeand/orreallocatetransportationresourcestoensuresufficienttransportationneedsaremet

Modificationtophysicalenvironment

Increaseinaccessto/optionsfortechnology(i.e.installationofanotherphoneline,purchaseofacomputer/cellphone,accesstotheinternet)

Developandimplementstrategiestoengagenaturalresourcesforpeoplesupportedinthesetting

Developandimplementstrategiestoengagethecommunityforcommunityinclusionoptionsforpeoplesupported

Update/Revisepoliciesandproceduresapplicabletothesetting

Trainsupervisors,administrators,anddecisionmakerswithintheorganizationinperson-centeredorganizationalpracticesandcoaching

Other,pleasespecify Typehere

Trainstaffonhowtohelppeoplemakeinformedchoices



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3)Eachperson’sHabilitationPlansincorporatesthemeaningfulandindividualizedcommunitybasedactivitiesthatthepersonwantsincludingdesiredfrequencyandsupportsneeded.



4)Eachperson’sPlanreflectstheriskfactorsandthepositivesafeguardingmeasuresinplacetominimizethemincludingindividualizedbackupplansandstrategieswhenneeded(thatcontributetotheperson’sabilitytoengageinmeaningfulactivities).

Reorganizeand/orreallocatestaffingresourcesand/orstaffingpatternstohelpsupportpeople'sinformedchoices

Increaseintransportation/transportationoptionstosupportinformedchoices

Reorganizeand/orreallocatetransportationresourcestoensuresufficienttransportationneedsaremettohonorinformedchoices

Developandimplementexperiementallearningstrategieswithpeoplesupported





Trainpeoplesupportedtoselfadvocate



Trainstaffoncommunityactivitiesandresourcesandhowtohelppeoplechooseandexperiencenewthings

Trainstaffonhowtoutilizeandassistwithuseofothertransportationoptions

Trainindividualssupportedonoptionsavailableformeaningfulcommunitybasedactivities

Trainfamiliesand/oradvocatesonoptionsavailableformeaningfulcommunitybasedactivities

Reorganizeand/orreallocatestaffingresourcestohelpfacilitiateandsupportpeople'schoiceofmeaningfulactivities

Increaseintransportation/transportationoptions

Reorganizeand/orreallocatetransportationresourcestoensuretransportationtomeaningfulactivities






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5)Eachperson’sPlanreflectsculturalconsiderationsandiswritteninplainperson-centeredlanguagethatisunderstandabletohim/her(e.g.,writteninpreferredlanguageincludingBrailleifnecessary).



6)Eachpersondirectstheirplanningprocessandchooseswhoparticipates.Theplanningprocessistimelyandoccursinthelocationandatatimethatisconvenientforeachperson.Eachpersonismadeawarethathe/shemayrequestaplanchange.Planchangesrequestedaremadewithinreasonabletimeframes.

Trainstaffondignityofriskandpositivesafeguarding

Trainindividualssupportedontheirrighttomakeinformedchoicesandhavedignityofrisk

Trainindividualsoneononeabouthowtoaddresshis/herownpersonalriskfactors

Trainfamiliesand/oradvocatesontherightsoftheindividualtomakeinformedchoicesandhavedignityofrisk

Implementthestrengthsandrisksinventorytoolorothertoolstohelpgeneratemeaningfulconversationswithpeopleregardingpossibleriskareasandtoemploydecisionmakingindecidingwhatrisksaretolerableandwhatrisksarenonnegotiableandpossiblyrequirearightsmodification

Reorganizeand/orreallocatestaffingresourcestoensuredignityofriskandpositivesafeguarding

Reorganizeand/orreallocatetransportationresources

Useofappropriatetechnologytohonordignityofriskandensurepositivesafeguards





Trainstaffonuseofplainlanguage,culturalcompetency,andcommunicatingwitheachpersoneffectively

Trainindividualssupportedontheirrighttounderstandinformation

Trainfamiliesand/oradvocatesontherightsoftheindividualstounderstandinformation

Increaseinaccessto/optionsfortechnologythatcanfacilitatecommunication(i.e.installationofanotherphoneline,purchaseofacomputer/cellphone,accesstotheinternet)




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7)Theplanningprocessincludesstrategiesforsolvingconflictsordisagreementsandincludesclearconflictofinterestguidelinesforallinvolved.



8)Eachperson’ssupportsareindividualizedanddonotrelysolelyonactivitiesinlargegroups.



Trainpeopletoselfadvocate

Trainstaffinpeople'spersoncenteredplanningrightsandhowtohelppeopleexercisethoserights

Trainindividualssupportedontheirpersoncenteredplanningrights

Trainindividualsonhowtodirecttheplanningprocessandmakeinformedchoices

Trainfamiliesand/oradvocatesontherightsoftheindividualtodirecttheplanningprocessandmakeinformedchoices

Engageandempowerdirectsupportprofessionaltoparticipateinplanningprocesswithpeopletheysupportwhendesiredbytheperson




Trainstaffonstrategiesforsolvingconflictsanddisagreementseffectively

Trainindividualssupportedonstrategiesforsolvingconflictsanddisagreementseffectively

Trainindividualssupportedontheirrightsandwheretogotoreceivehelpaddressingconflictsanddisagreements

Trainindividualssupportedonhowtomakeananonymouscomplaint

Update/Revisepoliciesandproceduresapplicabletoconflictsofinterestanddisagreements


Trainstaffonhowtofacilitateandsupportindividualizedoptionsthataremeaningfultoeachperson

Implementstrategiesandprocessestolearnaboutwhatismeaningfultoeachpersonandfacilitatetheseactivitiesandcorrespondingneededsupports

Reorganizeand/orreallocateand/orincreasestaffingresourcestohelpfacilitateandsupportactivitiesthataremeaningfultoeachperson

Reorganizeand/orreallocateand/orincreasetransportationresourcestohelpfacilitateindividualizedactivitiesmeaningfultoeachperson

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9)Opportunitiesfordecisionmakingarepartofeachperson’severydayroutine.



10)Whenapersonexpressesdissatisfactionwithsupports,services,livingsituation,roommate,etc.settingstaffsupportsthepersontomakelifeandsituationalchangesashe/shechooses.



Trainstaffandindividualsonhowtousetechnologiessuchastheinternettoidentifyoptionsthatmaybeofinteresttopeoplesupported





Facilitateopportunitiesforeachpersontoexperiencealternativesbeforemakingdecisions

Trainstaffonhowtofacilitateandsupportindividualizeddecisionmakingaspartofeachperson'severydayroutine

TrainIndividualssupportedonmakingeverydaydecisionsintheirlives

Trainfamiliesand/oradvocatesontheindividualsrighttomakeeverydaydecisionsintheirlives

Implementstrategiesandprocessestoincreaseeachperson'slevelofautonomy



Developandimplementanongoingprocesstolearnabouteachperson'ssatisfactionwithsupports,services,livingarrangement/roommate,etc.andtakeactionasneededbasedonwhatislearned

Trainstaffonlisteningskillsincludingobservingnonverbalcuesandotherwaystolearnwhatpeoplelikeanddonotlike

Trainindividualssupportedontheirrightsandoptions

Trainfamiliesand/oradvocatesontherightsandoptionsoftheindividual




Trainstaffonhelpingpeopletoidentifythechangesthattheywanttomaketoincreasetheirhappinessandsatisfaction

Implementstrategiestohelppeoplechoosetheirroommatesandmakechangesasneeded

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Page7

FULLACCESSTOTHECOMMUNITY:


11)Eachpersonisencouragedandsupportedtohavefullaccesstothebroadercommunitybasedonhis/herinterests/preferences/prioritiesformeaningfulactivitiestothesamedegreeasothersinthecommunity.



12)Settingstaffprovidesongoing/regularoptionsforcommunityintegrationandutilizationinlieuofon-siteservices?



Trainstaffontechniquesusedtofacilitateandsupporteachpersontoparticipateinscheduled/unscheduledcommunityactivitiesinthesamemanneraspeoplenotreceivingHCBS(e.g.shop,attendreligiousservices,appointments,lunch/activitieswithfamilyandfriends,etc.)inthecommunityastheychoose

Individualizesupportsaccordingtoeachperson'sinterestsandpreferences

Trainstaffinhowtoworkwithpeopletomaximizefullaccesstothecommunity

Trainindividualssupportedontheirrightstohavefullaccesstothecommunityandhowtomakeinformedchoicesinthisarea

Trainfamiliesand/oradvocatesontherightsoftheindividualtohavefullaccesstothecommunityandhowtomakeinformedchoicesinthisarea

Provideaccesstothematerialsandsupportsthatwillassistpeopleingainingcompetenciesandparticipatingfullyinpreferredactivities

Reorganizeand/orreallocateand/orincreasestaffingresourcestoensuresufficientstaffingtosupportfullaccesstothecommunitybasedoneachperson'sneedsandpreferences

Reorganizeand/orreallocateand/orincreasetransportationresourcestoensuresufficienttransportationtofacilitateandsupportfullaccesstothecommunity

Increaseinaccessto/optionsfortechnology(i.e.installationofanotherphoneline,purchaseofacomputer/cellphone,accesstotheinternet)tofacilitateandsupportfullaccesstothecommunityforeachperson

Developandimplementstrategiestoengagenaturalresourcestomaximizefullaccesstothecommunityforeachperson

Developandimplementstrategiestoengagethecommunityforcommunityinclusionoptionsforeachpersonsupported

Developandimplementstrategiestoencouragespontaneityinchoiceofactivities

Developandimplementactionsthathelpconnectpeoplewithrelatives,friends,communitymembers,etc..




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13)Exceptincasesofdocumentedandappropriaterightsmodifications,eachpersonisabletocomeandgofromthesettingatanytime.















Staffcommunicateandprovidesmaterialstopeopletoensurethattheyareawareofactivitiesoccurringinthecommunityinordertohelpthemmakeinformedchoicestoparticipateandprovideforsupportoftheseactivities




Trainstaffonpeople'srighttocomeandgoatanytimeandappropriaterightsmodificationsimplementation

Trainindividualssupportedontheirrightstocomeandgoatanytimeandhowtobesafeindoingso

Trainfamiliesand/oradvocatesontherightsoftheindividualtocomeandgoatanytimeandhowtobesafeindoingso

Modifythephysicalenvironmentinwaysthatcanhelpfacilitateandsupportthisrightforpeople

Increaseinaccessto/optionsfortechnologythatcanhelpfacilitatethisright

Implementmanagementstrategiestoensuretherearenoinappropriaterightsrestrictionsandpracticesthatinappropriatelyrestrictfreedomofmovement



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14)Exceptincasesofdocumentedandappropriaterightsmodifications,eachpersoninthesettingisaffordedthedegreeofcommunityintegrationdesiredbytheperson.







Trainfamiliesand/oradvocatesontherightoftheindividualtohavefullaccesstothecommunityandhowtomakeinformedchoicesinthisarea












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Page8

RIGHTS:


15)Exceptincasesofdocumentedandappropriaterightsmodifications,eachpersonhasaccesstofoodandcaneatwhen/where/andwithwhomtheychoose(inthesamemanneraspeoplewhodonotreceiveHCBS).



16)Personalinformationiskeptprivate;assistancewithpersonalcareisdoneinprivate;andeachpersonisaffordedprivacyinthesamemanneraspeoplenotreceivingHCBS(e.g.peopleknockandreceivepermissionbeforeaccessingprivatespace).



17)Exceptincasesofdocumentedandappropriaterightsmodifications,eachpersonchooseswhotointeractwithandwhen.

Personcenteredplanningtodeterminepreferencesanddesiredchoicesforwhen,where,andwithwhomtoeat

Stafftraining(forallthoseworkingwithinthesetting)

Trainindividualssupportedontheirrights

Trainfamiliesand/oradvocatesontherightsofindividuals

Increasesand/orchangesinstaffingpatterns

Modificationtophysicalenvironmenttoensureaccesstofood



Usepersoncenteredplanningtodeterminepreferencesforprivacy,personalcare,assistance,andlocation

Stafftraining(forallthoseworkingwithinthesetting)tosupportprivacyandprivacychoices

Trainindividualssupportedontheirrighttoprivacy

Trainfamiliesand/oradvocatesontherighttoprivacyoftheindividual

Review/oversightofphysicalenvironmenttoensurepersonalinformation,bothwrittenandverbal,iskeptprivate

Update/Revisepoliciesandproceduresapplicabletothesettingonprivacyofpersonalinformation


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18)Eachpersonhasameanstosecurepersonalbelongings.



19)Exceptincasesofdocumentedandappropriaterightsmodifications,eachpersonisallowedvisitorsoftheirchoiceatanytime.



UseofaPersonCenteredPlanningmethodologytodeterminepreferencesandchoicesincludinghowoftenandthekindofinteraction

Stafftraining(forallthoseworkingwithinthesetting)tosupportinteractions


Trainfamiliesand/oradvocatesontherightsoftheindividual

Reorganizeand/orreallocateand/orincrease/changeofstaffingresourcestoensuresufficientsupport

Increaseintransportation/transportationoptionstosupportinteractions

Reorganizeand/orreallocatetransportationresourcestosupportinteractions

Increaseinaccessto/optionsfortechnology(i.e.installationofanotherphoneline,purchaseofacomputer/cellphone,accesstotheinternet)inordertofacilitateinteractions

Developandimplementstrategiestoengagenaturalresourcesforpeoplesupportedinthesettingtoincluderelationshipsoutsidethesetting




UseofaPersonCenteredPlanningmethodologytoensurepreferencesandchoiceforlocationtosecurepersonalbelongings

Stafftraining(forallthoseworkingwithinthesetting)toprovidesupport

Trainindividualssupportedontheirrighttosecurepersonalbelongings

Trainfamiliesand/oradvocatesontherightsofindividualstosecurepersonalbelongings

Modificationtophysicalenvironmenttoensuremeanstosecurepersonalbelongings



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20)Exceptincasesofdocumentedandappropriaterightsmodifications,eachpersonaccessesthesettingandpersonalspace(ifapplicable)inthesamemanneraspeoplewhodonotreceiveHCBS(e.g.,forresidential,peoplehavekeystotheirunitsandcanlocktheirbedroomdoorswithonlyappropriatestaffhavingkeysiftheysochooseand/oralternativemeansareofferedforthosewhocannotusekeys);andeachpersonhasfreedomofmovementwithinthesetting(andarenotrestrictedtooneroomordesignatedarea).



21)Exceptincasesofdocumentedandappropriaterightsmodifications,eachpersonispermittedtohaveapersonalcellphone,computer,orotherdeviceforprivatecommunicationatanytime.

UseofaPersonCenteredPlanningmethodologytodeterminepreferencesandchoiceofvisitorsincludingtimes

Stafftraining(forallthoseworkingwithinthesetting)tosupportvisitations

Trainindividualssupportedontheirrighttohavevisitorsatanytime

Trainfamiliesand/oradvocatesontherightsofindividualstohavevisitorsatanytime

Modificationtophysicalenvironmentifneededtoprovideprivatespaceforvisits

Increaseinaccessto/optionsfortechnology(i.e.installationofanotherphoneline,purchaseofacomputer/cellphone,accesstotheinternet)tofacilitatearrangingvisitsifpreferred

Update/Revisepoliciesandproceduresapplicabletothesettingforvisitorsatthesetting



UseofaPersonCenteredPlanningmethodologytodeterminechoiceandpreferencesforaccesstothesettingandpersonalspace

Stafftraining(forallthoseworkingwithinthesetting)tosupportaccess

Trainindividualssupportedontheirrightstohavehelponlockingmechanisms

Trainindividualsontheirrighttohavefreedomofmovementwithinasetting

Trainindividualsontheirrighttoaccessthesettingandpersonalspace

Trainfamiliesand/oradvocatesontheindividualsrighttohavefreedomofmovementwithinasetting

Trainfamiliesand/oradvocatesontherightoftheindividualtoaccessthesettingandpersonalspace

Reorganizeand/orrelocatestaffingtoensurefreedomofmovement

Modificationtophysicalenvironmentifneededtoincludelockingmechanismtosettingandpersonalspaceand/orremovalofbarriersorobstructionsthatrestrictmovementwithinthesetting

Update/Revisepoliciesandproceduresapplicabletothesettingtoincludeprocesstoofferindividualslockingmechanismstothesettingandpersonalspaceandfreedomofmovementandaccess



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22)Therearenoblanketrules,policies,procedures,orpracticesthatlimitindividualrights,independence,choices,orautonomy.



23)Exceptincasesofdocumentedandappropriaterightsmodifications,eachpersonisnotprohibitedfromengaginginanylegalactivity.



UseofaPersonCenteredPlanningmethodologytodeterminechoicesandpreferencesforcommunicationaswellasanassessmentforaccessibletechnologyordevice

Stafftraining(forallthoseworkingwithinthesetting)tosupportcommunicationchoices

Trainindividualssupportedontheirrightstocommunicationdevicesandprivacy

Trainfamiliesand/oradvocatesontherightoftheindividualtocommunicationdevicesandprivacy

Ensuresufficientstaffingtosupportchoiceandpreferencesforcommunicationmethods




Stafftraining(forallthoseworkingwithinthesetting)toupholdrights

Trainindividualssupportedontheirrighttoindependenceandautonomy

Trainfamiliesandoradvocatesontherightsofindividualstoindependenceandautonomy

Higherlevelstaffperformunannouncedvisitstothesettingtoobserveandensurepracticesandstaffcompetencies




UseofaPersonCenteredPlanningmethodologytodeterminechoicesandpreferencesforactivitiesandtoensurealllegalactivitiesaresupported

Stafftrainingonrights(forallthoseworkingwithinthesetting)tosupportchoicesoflegalactivities

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24)Exceptincasesofdocumentedandappropriaterightsmodifications,eachpersonhasaccesstoandcontroloftheirpersonalresources.



25)Eachpersonisfreefromcoercion,restraint,andinappropriaterestrictionsandinterventions.



Trainindividualssupportedontheirrighttoparticipateinlegalactivities

Trainfamiliesand/oradvocatesontherightoftheindividualstoparticipateinlegalactivites

Update/Revisepoliciesandproceduresapplicabletothesettingonrights



UseofaPersonCenteredPlanningmethodologytodeterminechoicesandpreferencesonhowpersonalresourcesareaccessedandcontrolled

Stafftraining(forallthoseworkingwithinthesetting)onhowindividualscancontroltheirresources

Supportindividualstoaccesstheirpersonalresources

Trainfamiliesand/oradvocatesontherightofindividualstoaccesstheirpersonalresources

Increaseinaccessto/optionsfortechnology(i.e.installationofanotherphoneline,purchaseofacomputer/cellphone,accesstotheinternet)asneededtosupportaccesstoandcontrolofresources

Engagenaturalresourcesforpeoplesupportedinthesettingforeducationonresourcemanagement




UseofaPersonCenteredPlanningmethodologytoensurechoicesandpreferencesaswellastodocumentappropriatelyanyrestrictionsand/orinterventions

Stafftraining(forallthoseworkingwithinthesetting)onrightofindividualssupportedincludingmethodstoofferavarietyofchoicestopeoplesupportedinallactivitiesandcommunitysettings

Trainindividualssupportedontheirrightstobefreefromcoercion,restraint,andinappropriaterestrictionsandinterventions

Trainfamiliesand/oradvocatesontherightsofindividualstobefreefromcoercion,restraint,andinappropriaterestrictionsandinterventions

Update/Revisepoliciesandproceduresapplicabletothesettingonpoliciesforrightsrestrictionsandinterventions


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26)Anyrightsmodificationsalignwithrequirementsincludingdocumentationofanindividualizedandassessedneed;justificationforthemodification;documentationofpreviouspositiveandlessintrusivemethods,collectionandreviewofdata,establishedtimelimitsforperiodicreviewofthemodification,andobtainingtheinformedconsentoftheperson.




UseofaPersonCenteredPlanningmethodologyincludingchoicesandpreferences,aswellasthedocumentationonthejustificationofthelimitsforperiodicreviewofanyrightsmodification

Stafftraining(forallthoseworkingwithinthesetting)onrightsmodificationsthatarebasedonassessedneed

Trainindividualssupportedontheirrightstobefreefromcoercion,restraint,andinappropriaterestrictionsandinterventions

Trainfamiliesand/oradvocatesontherightsofindividualstobefreefromcoercion,restraint,andinappropriaterestrictionsandinterventions

Update/Revisepoliciesandproceduresapplicabletothesettingonpoliciesforrightsmodificationsandinterventions



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Page9

PHYSICALSETTING:


27)Exceptincasesofdocumentedandappropriaterightsmodifications,eachpersonhasfullunrestrictedaccesstospacesinthesettinginthesamemanneraspeoplewhodonotreceiveHCBS(e.g.Allbathroomsatthelocation,breakrooms,kitchenwithcookingspaceinthehome;laundryinthehome,etc.)



28)Thesettingreflectseachperson’sneedsandpreferencesincludingthepresenceofanyphysicalmodificationsifnecessary.Forexample,forpeoplewhoneedsupportstomoveaboutthesettingastheychooseandtofullyutilizesettingfeatures,thesettingprovidesgrabbars,bathroomseats,ramps,etc.



UseofaPersonCenteredPlanningmethodologythatincludeschoiceandpreferencesforactivitiesand/oruseofalllivingspacesatsetting


Trainindividualssupportedontheirrighttofullunrestrictedaccesstolivingspaces

Trainfamiliesand/oradvocatesontherightsofindividualstofullunrestrictedaccesstolivingspaces

Increasesand/orchangesinstaffingpatternstosupportaccess

Reorganizeand/orreallocatestaffingresourcestoensuresufficientstaffingneedsaremettosupportindividualsrighttofullaccesstolivingspaces

Modificationtophysicalenvironmenttoprovidefullaccesstolivingspacestoensuresiteisphysicallyaccessibleandfreeofobstruction



UseofaPersonCenteredPlanningmethodologythatidentifiestheindividualsneedsandpreferencesformodificationstosupportfullutilizationofthesettingincludingcreativeadaptivesolutions

Trainstafftosupportmodifications

Trainindividualssupportedontheirrightforfullutilizationofthesetting

Trainfamiliesand/oradvocatesontherightsofindividualstofullutilizationofthesetting


Reorganizeand/orreallocatestaffingresourcestoensuresufficientstaffingneedsaremetinordertosupportfullutilizationofthesetting

Modificationtophysicalenvironmenttosupportfullutilizationofthesettingincludingcreativeadaptivesolutions

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29)Thesettingisphysicallyaccessibleandtherearenoobstructionssuchassteps,lipsondoorways,narrowhallways,etc.limitingmobilityinthesettingoriftheyarepresentthereareenvironmentaladaptationssuchasastairliftorelevatortoamelioratetheobstruction.



Increaseinaccessto/optionsfortechnologyifneededtosupportfullaccessandutilization


UseofaPersonCenteredPlanningmethodologytodetermineneedsandpreferencesforenvironmentaladaptationsasneededtofullyaccessthesite

Trainstaffonrequirementsandmethodstokeepthesettingphysicallyaccessibleforpeoplereceivingservices

Trainindividualssupportedontheirrighttofullaccessibilityofthesite

Trainfamiliesand/oradvocatesontherightsofindividualstofullaccessibilityofthesite

Modificationtophysicalenvironmenttoensurethatthesettingisfullyaccessible

Update/Revisepoliciesandproceduresapplicabletothesettingtoincludeperiodicreviewsofthephysicalsettingtoensurefullaccessibilityandlackofobstruction


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Page10

STAFFINGANDCOMPETENCIES:


30)Paidandunpaidstaffreceivetrainingandcontinuingeducationrelatedtotherightsofpeoplereceivingservices,supportinginformedchoiceanddecisionmaking,andtheHCBSsettingsrules.



31)ThesettinghasimplementedDSPcompetenciesandtheevaluationprocess.



32)Thereissufficientstaffingand/orresources(e.g.,volunteersandnaturalsupports)toaddresseachperson’sneedsandindividualizedPlanprioritiesforcommunityinclusionandintegrationactivitiesoutsideofthesetting.



Stafftraining,initialandongoing(forallthoseworkingwithinthesetting)onrights,informedchoice,decisionmaking,andHCBSsettingsrules

TrainindividualssupportedontheirrightsincludingtheHCBSsettingrules

Update/Revisepoliciesandproceduresapplicabletothesettingtoincluderelatedstafftrainingwithproviderstotrainpaidandunpaidstaff



Stafftraining(forallthoseworkingwithinthesetting)anddocumentationofimplementationofDSPcompetenciesandevaluatingprocess

TrainindividualssupportedonagencypracticerelatedtoDSPcompetencies


Supervisors,administrators,anddecisionmakersaretrainedonDSPcompetenciesandtheevaluationprocess


UseofaPersonCenteredPlanningmethodologythatdocumentseachperson'sneedsandprioritizingforcommunityinclusionandintegration

Stafftraining(forallthoseworkingwithinthesetting)oneachpersonsindividualplantopromotecommunityinclusionandintegration

Trainindividualssupportedontheirrighttocommunityinclusionandintegration

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Trainfamiliesand/oradvocatesontherightsoftheindividualstocommunityinclusionandintegration


Reorganizeand/orreallocatestaffingresourcestosupporteachperson'sneedsandprioritiesforcommunityinclusionandintegration

Increaseintransportation/transportationoptionstoensuresufficienttransportationneedsaremet

Reorganizeand/orreallocatetransportationresourcestoensuresufficienttransportationneedsaremet





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Page11

E-2.TypeofSetting

SettingSpecificQuestions

WhattypeofsettingisbeingassessedonthisSelf-Report

Residential

Non-Residential

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Page12

Provider-OwnedorControlledResidentialSettings

ThefollowingquestionsareonlypertinentforSelf-Reportscompletedforresidentialsettings

33)Eachpersonhashis/herownbedroomorsharesaroomwithachoiceofroommate(s).


34)Eachpersonwhoneedsassistancetodressaredressedintheirownclothesappropriatetothetimeofdayandpersonalpreferences.


35)Eachpersonisdressedinclothesthatfit,areclean,andareappropriatetothetimeofday,weather,andpreferences.

Trainsettingstaffonpersoncenteredplanningrights,howtohelppeoplemakeinformedchoicesandhonoringchoices


Trainindividualssupportedontheirrights,howtomakeinformedchoicesandhowtoself-advocate


Engageandempowerdirectsupportprofessionalstoparticipateinplanningprocesswithpeopletheysupportwhendesiredbytheperson





Reviewandreviseservice/habilitationplansusingapersoncenteredmethodology









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36)Eachpersonwhoneedsassistancewithgroomingaregroomedastheydesire.


37)Eachpersonhasprivacyintheirsleepingorlivingunit.

















Reorganizeand/orreallocatestaffingandorincreaseresourcestoensuresufficientstaffingtoaddresspeople'sprivacypreferences





Stafftraining(forallthoseworkingwithinthesetting)tosupportprivacyandprivacychoices


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38)Homes/unitshaveentrancedoorslockablebytheperson,withonlyappropriatestaffhavingkeystodoors.


39)Bedroomshaveentrancedoorslockablebytheperson,withonlyappropriatestaffhavingkeystodoors.




Trainfamiliesand/oradvocatesontherightsofindividualsandtherighttoprivacy


Usepersoncenteredplanningtodeterminepreferencesforprivacy






Stafftraining(forallthoseworkingwithinthesetting)tosupportaccess,privacyandprivacychoices

Trainindividualssupportedontheirrightstohavelockingmechanismsandtheirrighttoaccessthesettingandpersonalspace


Trainfamiliesand/oradvocatesontheindividual’srighttohavefreedomofmovementwithinasettingandtoaccessthesettingandpersonalspace



Usepersoncenteredplanningtodeterminepersonalpreferences

Modificationtophysicalenvironmentifneededtoincludelockingmechanismtosettingand/orremovalofbarriersorobstructionsthatrestrictmovementwithinthesetting

Update/Revisepoliciesandproceduresapplicabletothesettingtoincludeprocesstoofferindividualslockingmechanismstothesettingandfreedomofmovementandaccess




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40)Eachpersonselectedtheresidentialsettingfromamongsettingoptionsincludingnon-disabilityspecificsettings.

40a)Specifytheworkplanactionitem.

41)Exceptincasesofdocumentedandappropriaterightsmodifications,eachpersonhasaccesstofoodatanytime.


Stafftraining(forallthoseworkingwithinthesetting)tosupportaccess,privacyandprivacychoices

Trainindividualssupportedontheirrightstohavelockingmechanismsandtheirrighttoaccessthesettingandpersonalspace


Trainfamiliesand/oradvocatesontheindividual’srighttohavefreedomofmovementwithinasettingandtoaccessthesettingandpersonalspace



Usepersoncenteredplanningtodeterminepersonalpreferences

Modificationtophysicalenvironmentifneededtoincludelockingmechanismtobedroomand/orremovalofbarriersorobstructionsthatrestrictmovementwithinthesetting

Update/Revisepoliciesandproceduresapplicabletothesettingtoincludeprocesstoofferindividualslockingmechanismstothebedroomandfreedomofmovementandaccess



Trainstaffonhowtohelppeoplemakeinformedchoices



Trainpeoplesupportedtoselfadvocate


Update/revisepoliciesandprocedures


Personcenteredplanningtodeterminepreferencesanddesiredoutcomesforwhen,where,andwithwhomtoeat




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42)Eachpersonhasthefreedomandsupporttocontroltheirownschedulesandactivities.


43)Exceptincasesofdocumentedandappropriaterightsmodifications,eachpersonisabletohavevisitorsoftheirchoosingatanytime.






Trainstaffontechniquesusedtofacilitateandsupporteachpersontoparticipateinscheduled/unscheduledcommunityactivitiesinthesamemanneraspeoplenotreceivingHCBS(e.g.shop,attendreligiousservices,appointments,lunch/activitieswithfamilyandfriends,etc.)inthecommunityastheychoose
















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44)Thesettingisphysicallyaccessibletoeachperson.

44a)Specifyworkplanactionitem.

45)Eachpersonhasthefreedomtofurnishanddecoratetheirsleepingorlivingunitswithintheleaseorotheragreement.

45a)Specifyworkplanactionitem.

UseofaPersonCenteredPlanningmethodologytodeterminepreferencesandchoiceofvisitorsincludingtimes

Stafftraining(forallthoseworkingwithinthesetting)tosupportvisitations

Trainindividualssupportedontheirrighttohavevisitorsatanytime

Trainfamiliesand/oradvocatesontherightsofindividualstohavevisitorsatanytime

Modificationtophysicalenvironmentifneededtoprovideprivatespaceforvisits

Increaseinaccessto/optionsfortechnology(i.e.installationofanotherphoneline,purchaseofacomputer/cellphone,accesstotheinternet)tofacilitatearrangingvisitsifpreferred

Update/Revisepoliciesandproceduresapplicabletothesettingforvisitorsatthesetting



UseofaPersonCenteredPlanningmethodologythatidentifiestheindividualsneedsandpreferencesformodificationstosupportfullutilizationofthesettingincludingcreativeadaptivesolutions

Trainstafftosupportmodifications

Trainindividualssupportedontheirrightforfullutilizationofthesetting

Trainfamiliesand/oradvocatesontherightsofindividualstofullutilizationofthesetting


Reorganizeand/orreallocatestaffingresourcestoensuresufficientstaffingneedsaremetinordertosupportfullutilizationofthesetting

Modificationtophysicalenvironmenttosupportfullutilizationofthesettingincludingcreativeadaptivesolutions

Increaseinaccessto/optionsfortechnologyifneededtosupportfullaccessandutilization






Increaseaccesstoactivitiesandoptionsthatareofinteresttopeoplesupported

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46)Eachpersonhasalegallyenforceableagreementfortheunitordwellingwheretheindividualresidesthataffordsevictionprotectionsandappealrights.

46a)Specifyaworkplanactionitem.



Implement/developaleaseagreementforpeopleservedinthesetting

UseofaPersonCenteredPlanningmethodologytodeterminechoiceandpreferences





Implement/developaleaseagreementforpeopleservedinthesetting



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Page13

Non-ResidentialSettings

ThefollowingquestionsareonlypertinentforSelf-Reportscompletedfornon-residentialsettings

47)Thesettingaffordsavarietyofmeaningfulnon-workactivitiesthatareresponsivetothegoals,interestsandneedsofeachperson.Thephysicalenvironmentsupportsavarietyofpeoples'goalsandneeds(forexample,thesettingprovidesindoorandoutdoorgatheringspaces;thesettingprovidesforlargergroupactivitiesaswellassolitaryactivities;thesettingprovidesforstimulatingaswellascalmingactivities).


48)Thesettingprovidesinformationoneachperson'srights.



Trainstaffonhowtohelppeoplemakeinformedchoicesandhowtoworkwithpeopletomaximizefullaccesstothecommunity

Trainstaffonactivitiesandresourcesandhowtohelppeoplechooseandexperiencenewthings

Trainindividualssupportedontheirrightsandhowtomakeinformedchoicesandtoself-advocate

Trainfamiliesand/oradvocatesontherightsofindividualstomakeinformedchoicesandonoptionsavailableformeaningfulactivities



Reorganizeand/orreallocatestaffingresourcestohelpfacilitateandsupportpeople'schoiceofmeaningfulactivitiesandtohelpsupportpeople'sinformedchoices

Increaseinaccessto/optionsfortechnology(i.e.installationofanotherphoneline,purchaseofacomputer/cellphone,andaccesstotheinternet)







Trainindividualssupportedontheirrightsandhowtomakeinformedchoicesandtoself-advocate


Trainstaffontherightsofindividualsandbestpracticesindistributingthisinformation

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49)Thesettingaffordsopportunitiesforeachpersontohaveknowledgeoforaccesstoinformationregardingage-appropriateactivitiesincludingcompetitivework,shopping,attendingreligiousservices,medicalappointments,diningout,etc.outsideofthesetting,andwhointhesettingwillfacilitateandsupportaccesstotheseactivities.


50)Eachpersonchosethesettingamongothersettingoptions.Settingoptionsofferedincludenon-disability-specificsettings,suchascompetitiveemploymentinanintegratedpublicsetting,volunteeringinthecommunity,orengagingingeneralnon-disabledcommunityactivitiessuchasthoseavailableataYMCA.




Developmaterialstoassistpeopleinunderstandingtheirrights



Trainstaffonhowtohelppeoplemakeinformedchoices,dignityofriskandpositivesafeguarding,andhowtoworkwithpeopletomaximizefullaccesstothecommunity

Trainstaffonactivitiesandresourcesandhowtohelppeoplechooseandexperiencenewthings

Trainindividualssupportedontheirrightsandhowtomakeinformedchoices,theirrighttohavedignityofrisk,andhowtoaddresshis/herownpersonalriskfactors

Trainfamiliesand/oradvocatesontherightsofindividualsandontherightsoftheindividualtomakeinformedchoicesandhavedignityofrisk

Trainfamiliesand/oradvocatesonoptionsavailableformeaningfulactivities












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51)ThesettingallowstheopportunityforeachpersontochoosetocombinemorethanoneservicedeliverysettingortypeofHCBSinanygivenday/week(e.g.combinedayhabilitationwithcommunityhabilitation).


52)Eachpersonisaffordedopportunitiestochoosewithwhomtodoactivitiesinthesettingoroutsidethesetting(i.e.,peoplearenotassignedonlytobewithacertaingroupofpeople).















Trainstaffonhowtofacilitateandsupportindividualizedoptionsthataremeaningfultoeachperson

Implementstrategiesandprocessestolearnaboutwhatismeaningfultoeachpersonandfacilitatetheseactivatesandcorrespondingneededsupports

Reorganizeand/orreallocateand/orincreasestaffingresourcestohelpfacilitateandsupportactivitiesthataremeaningfultoeachperson

Reorganizeand/orreallocateand/orincreasetransportationresourcestohelpfacilitateindividualizedactivitiesmeaningfultoeachperson


Trainfamiliesand/oradvocatesontherightsoftheindividual

Developandimplementstrategiestoengagenaturalresourcesforpeoplesupportedinthesettingtoincluderelationshipsoutsidethesetting



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Page14

F.WorkPlan:

Questionisrequired

Pleaseattachyourworkplan.Utilizenamingconvention:agency-OC#-wp(ex.opwdd-12345678-wp).

Ensuretheworkplanaddresseseachareawithinthissurveythatisnotyetcompliant.Evenoneresponseof"No"indicatesthataworkplanisneeded.AlsonotethatanyHCBSsettingstandardthatDQIsurveyorsidentifyas"NotMet"duringthesurveycyclebeginningOctober1st,2016willrequirecorrespondingworkplanactionitemsnolaterthan20daysaftertheDQIsurvey.Revised/amendedworkplansshouldbee-mailedtoheightened.scrutiny@opwdd.ny.gov.Includeagencyname,OC#ofthesetting,andsiteaddressfortherevised/amendedworkplanintheemailsubjectline.

WorkPlan:


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Page15

G.NARRATIVEINFORMATIONTHATDEMONSTRATESHOWTHESETTINGISHOMEANDCOMMUNITY-BASEDANDOVERCOMESTHEPRESUMPTIONTHATITISINSTITUTIONALAND/ORISOLATING:

Inyourresponse,considerhowthesettingprovidesfullaccessforEACHPERSONtothebroadercommunityincludingopportunitiestoseekemployment,workincompetitiveintegratedsettings,engageincommunitylife,controlpersonalresources,andreceiveservicesinthecommunitytothesamedegreeofaccessaspeoplenotreceivingHCBS.Additionally,agenciesshouldprovideevidencedemonstratingthatthereislittleornointerconnectednessoftheadministrativeandfiscaloperationsoffacilitiesthatprovideinpatienttreatmentORsettingslocatedonthegroundsorimmediatelyadjacenttoapublicinstitution.AlsofocusonhowthesettingensuresHCBSsettingcompliance.

Forsettingsthatareinapublicallyorprivately-ownedfacilitythatprovidesinpatienttreatmentORinabuildinglocatedonthegroundsoforimmediatelyadjacenttoapublicinstitution,pleaseprovideinformationanddocumentationshowingthattheHCBSsettingisnotoperationallyinterrelatedwiththefacilitysetting,suchas:

Interconnectednessbetweenthefacilityandthesettinginquestion,includingadministrativeorfinancialinterconnectedness,doesnotexistorisminimal.TotheextentanyfacilitystaffareassignedoccasionallyoronalimitedbasistosupportorbackuptheHCBSstaff,thefacilitystaffarecross-trainedtomeetthesamequalificationsastheHCBSstaff;Participantsinthesettinginquestiondonothavetorelyprimarilyontransportationorotherservicesprovidedbythefacilitysetting,totheexclusionofotheroptions;TheproposedHCBSsettingandfacilityhaveseparateentrancesandsignage;Thesettingisintegratedinthecommunitytotheextentthatapersonorpersonswithoutdisabilitiesinthesamecommunitywouldconsideritapartoftheircommunityandwouldnotassociatethesettingwiththeprovisionofservicestopersonswithdisabilities.

1)ProviderResponse:

Typehere

OPTIONAL:Ifthespaceprovidedaboveisnotadequate,includeadditionalinformationinanuploadedformat.AdditionalinformationmayalsoincludehowEACHpersonwithinthesettingisprovidedaccesstothebroadercommunitybasedontheirpersonalchoices.Ifmultipledocumentsarerequiredforupload,pleaseconsolidatetheminto1formatthatcanbeuploaded.Whenincludinganattachmenthere,pleaseutilizenamingconventionasfollows:

agency-OC#-addinfo(ex.opwdd-12345678-addinfo)

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OptionalUpload:

AdditionalInformation


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Page16Clickthe"Submit"buttonbelowtosubmityoursurvey.Donot"X"outofyoursurveyuntilyousubmityoursurvey.

Thankyou{{Name}}forcompletingthisimportantsurvey!Ifyouneedtochangeyourresponsesafteryousubmityoursurvey,pleasecontactCaseyDowneyat(518)[email protected]

Onthenextpage,youwillbeallowedtodownloadandprintyoursurvey.Pleasedownloadandprintthissurveyandkeeponsiteandaccessible.Thankyou.

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